Infertility Nursing - Omnia Education

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tHE OMnia cME JOURnal tm | sEPtEMBER 2011 Elective Single Embryo Transfer and the Patient Demands When discussing the topic of elective single embryo transfer (esEt) with patients, it is extremely important to confirm patient expectations and demands. as health professionals it is important to educate our patients and make certain they have realistic expectations. it is also important to be aware of the facts about the rising number of multiple births and the risks which are avoidable in many cases, as well as the increasing success rates of esEt. deciding whether to offer esEt depends on the clinical judgment of the health care practitioners involved. the decision should be based on an assessment of the risk of multiple births to the individual patient, taking into account their overall prognosis. When a patient is considering fertility treatment they will have many questions about the potential outcome including the risk of multiple births. it is important to answer questions about how esEt may affect the patient’s chances of getting pregnant. in addition patients must be informed about what will be done with remaining viable embryos and how they will be stored, as well as cost of cryopreservation and storage of remaining embryos. Which patients are suitable for Elective Single Embryo Transfer (eSET)? Making the decision about doing an esEt depends on a patient’s prognosis for getting pregnant after iVF. the woman with the best chance of getting pregnant after iVF is also at the highest risk of conceiving multiples. Relevant factors to consider include the following: • Patient’s age and general medical condition • Obstetric and gynecological history • number of previous failed iVF attempts • the patient’s ovarian response • the number and quality of embryos created • the availability of good quality embryos including blastocysts the importance of the overall prognosis cannot be understated. the american society for Reproductive Medicine (asRM) has identified “favorable prognosis patients” as those under 37 years of age (or using an oocyte donor under 37 years of age) without prior failed iVF cycles, who have morphologically good-quality embryos in sufficient number to warrant cryopreservation of the non-transferred embryos. 1 Furthermore, esEt is not just for patients under 37 years of age. the Human Fertilization and Embryology authority (HFEa), an independent regulating authority in the United Kingdom that oversees the use of gametes and embryos both in fertility treatment as well as research, has posted success rates for esEt for 2004 and 2005. 2,3 these indicate live birth rates of 23.7% and 18% retrospectively for patients over the age of 35, compared with the figures of 23.8% and 22.4% for the under 35. the HFEa also suggests that esEt can be successfully performed in older patients, 35–39 years, with good quality embryos. the number of previously failed iVF attempts needs to be taken author Adrienne Kramer, rn, rnc Senior Nurse Coordinator Reproductive Medical Associates of New Jersey morristown, nj peer reviewers Sanjay K. Agarwal, md, facog Clinical Professor of Reproductive Medicine University of California, San Diego la jolla, ca Eric S. Surrey, md, facog Medical Director Colorado Center for Reproductive Medicine lone tree, co medical editor Erem Latif, ms, medical physiology Medical Editor chantilly, va into consideration equally when targeting esEt to the right patients. this means that esEt is normally restricted to the first one to two iVF cycles regardless of the age of the patient. Recent international studies have been carried out using the following criteria: • Women under 34 who started their first iVF/intra-cytoplasmic sperm injection (icsi) cycle and had at least two good quality embryos. • Women of all ages who had at least 4 good quality embryos and no more than one failed treatment cycle. • Women under 36 years of age who had at least 2 good quality embryos. the asRM developed guidelines detailing the number of embryos transferred. 1 Multiple-gestation pregnancies remain the most significant and frequent complication of iVF treatment. although national and international efforts have focused on phasing out protocols that result in
higher order multiples, twin gestations continue to be a common accepted and surprisingly frequent desired outcome of iVF in the U.s. 4,5 twin gestations are certainly less risky than those involving high order multiples. compared with singletons, however, twin pregnancies contribute to the epidemic of preterm deliveries, have a higher rate of spontaneous abortion and intrauterine fetal demise and are more likely to result in neonatal and infant death, cerebral palsy and other congenital birth defects. 6-8 Guidelines on number of embryos transferred in an effort to reduce the incidence of high order multiple gestations, the asRM and the society for assisted Reproductive technology (saRt) has developed the following guidelines to assist fertility programs and patients in determining the appropriate number of embryos—cleavage-stage (day 3 after fertilization ) or blastocyst (day 5-6 after fertilization), to transfer. these guidelines may be modified accordingly to the individual clinical conditions including patient age, embryo quality and the opportunity for cryopreservation. 1 in the absence of data generated by the individual iVF program and based on the data generated by all clinics providing aRt services, the following guidelines are recommended based on data available in 2009 asRM guidelines. a. For patients under the age of 35 and 37 years who have a favorable prognosis, considerations should be given to transferring only a single embryo. no more than two embryos (cleavage stage or blastocysts) should be transferred. B. For patients between 35 and 37 years of age who have a more favorable prognosis, no more than two cleavagestage embryos should be transferred. all others in this age group should have no more than three cleavage-stage embryos transferred. if extended culture is performed, no more than two blastocysts should be transferred to women in the age group. c. For patients between 38 and 40 years of age who have a more favorable prognosis, no more than three cleavage-stage embryos or two blastocysts should be transferred. all others in this age group should have no more than four cleavage– stage embryos or three blastocysts transferred. d. For patients 41–42 years of age, no more than five cleavage-staged embryos or three blastocysts should be transferred. E. in each of the above age groups for patients with two or more previous failed, fresh iVF cycles or a less favorable prognosis, one additional embryo may be transferred according to the individual circumstances. 1 the patient must be counseled regarding the risks of multifetal pregnancy. Both the counseling and the justification for exceeding the recommended limits must be documented in the patient’s permanent medical record. F. in women 43 years of age or older there is insufficient data to recommend a limit on the number of embryos to transfer. g. in donor egg cycles, the age of the donor should be used to determine the appropriate number of embryos to transfer. H. in frozen transfer cycles, the number of good-quality, thawed embryos transferred should not exceed the recommended limit on the number of fresh embryos transferred for each age group. 1 Most professional societies have issued guidelines to decrease the number of embryos transferred during assisted reproductive techniques. despite this, the incidence of multiple pregnancies remains high. although triplet pregnancies have been reduced dramatically in the United states by limiting the number of embryos transferred, twin pregnancies still make up roughtly one third of all births from assisted reproductive technology. 9 despite recent guidelines from the asRM, which suggest consideration of single embryo transfer in patients with the most favorable prognosis, there has been considerable resistance in the U.s. 7 Many physicians and patients fear that elective single embryo transfer may reduce overall pregnancy rates. 7 Multiple births are hailed by many as a miracle and the novelty of high order multiples has been a source of fascination if not entertainment since the 1930s. the medical community however is not so emamored by these “multiple multiples.” Multiple births present potiential acute and long-term medical risks to the pregnant woman and to the children. 8-10 Risks to the children include prematurity, which can contribute to the high incidence of low birth weight among multiples. low birth weight significantly impacts infant morbidity and mortality. Multiples may also suffer long term medical and developmental problems. 9 Multiple births also pose long term and short term medical risks to a woman including premature labor and delivery, pregnancy-induced hypertension, gestational diabetes and increased risk of hemmorhage. these women may require extended periods of time on bedrest, be hospitalized and often require administration of medication to prevent preterm labor. 10 8
Page 1 and 2: the Omniacme journaltm special edit
Page 3 and 4: Beyond Clomiphene - What’s Next?
Page 5 and 6: centers may perform 2 iUis once at
Page 7: conclusion Beyond clomid, infertili
Page 11 and 12: considered normal only if it has 2
Page 13 and 14: The Patient and Multiple Births: Bl
Page 15 and 16: even spiritual support opportunitie
Page 17 and 18: POst-tEst instructions for credit P
Page 19 and 20: Receive up to 15 Credit Hours ! 5 R

Infertility Nursing - Omnia Education

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